Protocol for Evaluating a Novel University-Based Clinical Training Course in Eye Movement Desensitisation and Reprocessing (EMDR) Therapy in Aotearoa New Zealand

Eye movement desensitisation and reprocessing (EMDR) therapy is an evidence-based psychological therapy for treating posttraumatic stress disorder (PTSD). PTSD is common, and is experienced by around 4% of people at some time in their lives (World Health Organization [WHO], 2013). Symptoms such as intrusive flashbacks, nightmares, negative thoughts and feelings and physical reactivity can have a severe impact on a person’s functioning. EMDR comprises a manualised protocol of therapy sessions. These involve clinical assessment followed by in-session exposure of the client to their traumatic memories combined with guided saccadic eye movements (simultaneously shifting both eyes). Shapiro, the developer of EMDR, put forward the adaptive information processing (AIP) model to explain the therapy’s underlying mechanism (Shapiro, 2018). This contends that the bilateral stimulation (BLS) provided by the eye movements allows for maladaptively stored trauma memories to be processed effectively. There has been ongoing debate around this, with a recent review of proposed mechanisms of action finding that clear conclusions were not possible and suggesting that there were potentially multiple concurrent underlying mechanisms associated with treatment gains (Landin-Romero et al., 2018).

EMDR therapy is one of only two therapeutic interventions recommended by the World Health Organisation (WHO) for the treatment of PTSD, alongside cognitive behavioural therapy (Tol et al., 2014; World Health Organization, 2013). EMDR therapy has also been endorsed in PTSD treatment guidelines developed in the United Kingdom (National Institute for Health and Care Excellence, 2018), Australasia (Royal Australian and New Zealand College of Psychiatrists endorsed Phoenix guideline; Phelps et al., 2022), South Africa (Seedat, 2013) and North America (American Psychological Association, 2017), as well as by several international societies including the International Society of Traumatic Stress Studies (2018). EMDR therapy is also increasingly used for the treatment of other anxiety-based disorders, where it has a growing evidence base (Faretta & Dal Farra, 2019; Valiente-Gómez et al., 2017). It has been trialled as a treatment for PTSD in New Zealanders with comorbid severe mental illness (Every-Palmer et al., 2019, 2023, 2023). There is also growing international support for the use of EMDR, including a small number of recent studies exploring cross-cultural adaptations (Carvalho & Hoersting, 2023; Mbazzi et al., 2021; Nickerson, 2022). These studies emphasised that there are differences in the application of therapies across cultures, with many groups experiencing inequitable general health outcomes, including in New Zealand (Wilson et al., 2022). This has led to important caveats around the applicability of evidence-based interventions cautioning against assuming they apply across all populations (Melchert et al., 2023).

EMDR training in New Zealand has historically been undertaken in the private sector through a North American training institute. This has led to concerns that contemporary EMDR training does not always account for the cultural contexts of our local environment. In addition, it has been noted that there has been little research into the training of healthcare practitioners in EMDR (Marich, 2009) and that contemporary EMDR training frequently lacks the rigour of university-delivered clinical training courses where more comprehensive teaching and competency assessments are possible. It was recommended some time ago that university-based EMDR therapy training should be developed (Farrell & Keenan, 2013), and more recently that this should include training that incorporates a comprehensive curriculum (Laliotis et al., 2021). Although some universities appear to have provided short courses, we are aware of only one other university that has provided a fully assessed academic course (i.e. the University of Worcester in the United Kingdom).

In response to this indicated gap, our research and teaching group successfully applied in 2022 to develop two full-year part-time special topic papers (courses) at the University of Otago in the applied practice of EMDR. These papers are: Special Topic (ST) 1, which is an introductory paper providing trainees with a comprehensive grounding in EMDR theory, and in the applied practice of EMDR therapy primarily for PTSD; and ST2, which is an advanced topic covering more advanced theory and practice. This advanced paper includes: treating complex trauma presentations (including dissociative comorbidity), phobias, obsessive compulsive disorders, depression, chronic pain, panic, abnormal grief and addiction disorders; delivering group EMDR therapy; and delivering EMDR for clients with severe mental illnesses (e.g. psychotic conditions such as schizophrenia and bipolar disorders) who have comorbid trauma related symptoms. ST1 was delivered for the first time in 2023 and will be delivered again in 2024 alongside ST2. The use of EMDR therapy for children is taught across both ST1 and ST2, with advanced skills taught in ST2.

After developing a curriculum and assessment framework for these courses, we intend to examine their efficacy and ensure that they are fit for purpose. A vital context of this broader research programme is the unique culture and environment where mental health conditions are to be treated by our students. In Aotearoa New Zealand, under The Treaty of Waitangi/Te Tiriti O Waitangi, we have particular obligations towards our Indigenous Māori population. Moreover, Māori and other minority groups are also overrepresented in adverse mental health outcomes (Oakley-Brown et al., 2006).

Study Aims

The present investigation will be an exploratory ‘proof of concept’ study (Ringsted et al., 2011) that will examine the initial feasibility of delivering university-based clinical training nationally. It will explore the outcomes and experiences of students, teachers and clients treated by students for our initial introductory EMDR practice course. The specific objectives of the project are as follows.

• Determine the demand for this university-delivered training (student enrolment/uptake).

• Trial the assessment of student progress in EMDR core competencies, including culturally responsive practice, using novel applications of formal psychometric measures incorporated in the CanMEDS (Frank et al., 2015) framework.

• Form a stakeholder advisory group of individuals with expertise and experience in EMDR from across the community to provide input into the evaluation.

• Consider student educational outcomes against: 1) course learning outcomes and 2) the Otago graduate profile attributes (i.e. qualities the University aims for its graduates to attain), particularly regarding cultural understanding. This includes developing knowledge and appreciation of biculturalism and multiculturalism and applying this knowledge in a culturally appropriate manner.

• Complete survey-based and qualitative assessments of student and teacher experiences of the course, and the experiences of clients treated by students taking the course.

The project will use a mixed methods approach incorporating co-design with key stakeholders to assist in developing a framework to evaluate culturally responsive practice. The results of this proof-of-concept investigation will inform the delivery of any future offerings of EMDR graduate courses delivered by the University.

Methods

Study Design

The course evaluation will incorporate a mixed methods study design (Combs & Onwuegbuzie, 2010), combining quantitative and qualitative approaches. The quantitative aspect of the study will focus on collecting students’ feedback (obtained through questionnaires) and assignment marks. The qualitative component will involve interviews with teachers, students and students’ clients on their perceptions and experiences of the course and clinical services received. This mixed-method framework will provide a comprehensive understanding by combining generalisable findings from quantitative data and context-specific insights from qualitative data (Onwuegbuzie & Combs, 2011). Using both approaches will allow for data triangulation and increase confidence in findings (Boet et al., 2012; McChesney, 2020).

Ethical Approval and Consent

This study was approved by the University of Otago Human Ethics Committee in New Zealand (Reference D23/071) and underwent Māori consultation with the Ngāi Tahu Research Committee. Written informed consent will be obtained from all study participants.

Participants and Recruitment

Eligible participants will include all students enrolled in ST1 in 2023 and all course teachers. A sample of clients who have received EMDR from those trained on the course will also be approached for participation.

All students enrolled in ST1 in 2023 will be invited to participate in this study. Information on the study will be presented in written form as well as verbally at in-person teaching days. Participants will be informed that taking part in the evaluation study will be optional and will not impact their participation in the course. They will also be informed that any data collected will be in de-identified or anonymous form. We aim to recruit 80% of enrolled students to take part in this research, and from this group will recruit a subsample of six to 10 students to take part in the post-course focus groups. All three teachers involved in the course will be invited to participate in a focus group/interviews following completion of the course. Finally, for the focus group study, we will add a subsample of clients who undertook treatment with students of the course.

Stakeholder Advisory Group

We will recruit an advisory group of community stakeholders with clinical, academic, health leadership, cultural, minority group and service-user (client) expertise to partner with us to produce a co-designed approach to assessing course outcomes that emphasises culturally responsive practice.

Course Description

The first-year EMDR therapy paper (PSME: 455) is a 30-point part-time introductory course on the applied practice of EMDR therapy (30 points represent 360 hours of work in total).

Aims and objectives. The paper aims to provide students with an introductory grounding in EMDR theory and the applied clinical practice of EMDR therapy.

Learning outcomes. Students completing the paper will be able to demonstrate knowledge and skills in the application of Phases 1–8 of the standard EMDR protocol based on the AIP model (Shapiro, 2018) for trauma-related disorders incorporating a critical understanding of how cultural influences relevant to Aotearoa New Zealand inform their work.

Teaching and learning approach. The content of the paper is determined by the EMDR framework, which is the basis for the courses taught around the world. This paper (as is ST2) is broadly equivalent to ‘certified/accredited clinician training’, which is recognised as providing an advanced level competency both in Aotearoa New Zealand and overseas. The paper is taught by recognised experts in the field and is based on internationally recognised best-practice research. The paper will be delivered by distance by integrating comprehensive training resources, in-person block-course teaching, independent self-directed study, and group supervision. The paper will be taught primarily through 30 hours of online lectures and two 2.5 day blocks (one in each semester) comprising 20 hours per block of in-person teaching. Each block course will include self-directed study tasks and skills practice (including self-experience) linked to modules of specified teaching and learning content. Lectures will build on pre-reading to expand understanding of EMDR, introduce treatment protocols and set up practice of these during practicum sessions. The practicums allow trainees to practice the specific therapy techniques in pairs, and to have a personal experience of EMDR therapy. Students will be required to undertake an additional 6 hours of self-study involving independent learning and clinical practice per week for the duration of the course.

Supervision programme. Student progress in knowledge and practice will be supported through their required attendance at structured small-group supervision with designated accredited training case consultants/supervisors. Students will be required to undertake 5 hours of supervision with their allocated training supervisor each semester. Students will be given templates for preparing their cases. Students will be expected to maintain separate clinical supervision with an appropriate mental health professional, in addition to seeing their training supervisors. Students will also be required to complete a client log (using a set template) after each EMDR therapy session in clinical practice, which will include their thoughts on what went well and what was problematic. This reflective technique allows for more focused questions to be brought to the supervision groups. Students will be encouraged to set up peer support groups to discuss course and clinical content to improve their understanding and preparation for formal supervision sessions and written assignments.

Terms requirements. To obtain terms and sit the final viva examination, students will be required to:

• Assess and treat a minimum of four clients presenting with posttraumatic stress using the EMDR therapy standard protocol.

• Complete 40 hours of EMDR practice each semester, from history taking and case conceptualisation through to active treatment of posttraumatic stress.

• Complete 10 hours of work with their training supervisor, who has established that the student has met the standards for the two required ‘entrustable professional activities’ (EPAs) (see below): 1) ‘Comprehensive assessment and case conceptualisation using the AIP model’; and 2) ‘Using the EMDR therapy standard protocol’.

Assessment procedures. There will be four assessment processes (Figure 1): two work-based components (observed clinical activities [OCAs] and case-based discussions [CBDs]); a written assignment; and a final viva (see the EMDR competency framework in Appendix 1). Formative assessment will be undertaken through initial attempts at the first three of these components, with structured, graded feedback given. Summative assessments of these components will contribute to final grades.

• OCAs are video recordings of practice, and will be evaluated with regard to the reprocessing phases of the standard EMDR protocol.

• CBDs will take place in individual or group sessions with the training supervisors. These focus on an evaluation of clinical reasoning about a client’s treatment. CBDs will be evaluated using a structured rating scale that covers Phases 1–8 of the standard EMDR protocol, along with professionalism and clinical reasoning.

• A written assignment is included to assess students’ capacity to communicate collaboratively and effectively in written form and to develop case conceptualisations and proposed treatment plans using the AIP model. The assignment has a 3000-word limit and is graded using a structured marking guide.

• A viva voce examination will be held at the conclusion of the second semester. It assesses the knowledge base not previously examined using the other assessment tools. In particular, it will examine the student’s capacity to demonstrate a detailed understanding of the AIP model and their ability to describe it verbally as if in a clinical environment.

• Taken together, the various forms of assessments cover the EMDR EPAs. These EPAs specify required standards across specified competencies pertaining to the practice of EMDR therapy (Appendix 1).

Competency framework. To monitor competency development, we are trialling the use of an EMDR-specific adaptation we developed from the CanMEDs measurement framework (Frank et al., 2015). This internationally established approach to assessing the development of clinician competence and patient care will enable us to evaluate clinical competency development over time. Assessing all of the individual skills necessary to do EMDR therapy would be prohibitive and run the risk of losing sight of the broader qualities of the attuned, compassionate, professional therapist. It may also lead to the promotion of clinicians being ‘EMDR technicians’ rather than EMDR therapists. Supporting the assessment of the broader competency of a clinician practising EMDR therapy allows for other clinical facets to be included. The CanMEDS approach allows for this, and incorporates robust psychometric assessment tools that can be used to measure training progress against core EMDR competencies. Little research has been published on formal competency assessment in EMDR training. A recent systematic review by Adams and colleagues (2020) recommended the use of the EMDR Fidelity Rating Scale (EFRS) in outcome studies to ensure adherence to treatment protocols. Our competency framework was informed by the assessment of fidelity for the reprocessing phases of the standard protocol (Phases 3–7) using the EFRS Version 2 (Korn et al., 2017). The paper’s learning outcomes and the 13 attributes of the University graduate profile (both are compulsory components of all Otago courses) have also been aligned with the CanMEDS competencies, enabling measurement of these aspects (Appendix 1).

Proof of Concept Outcomes

Course uptake. This will be assessed by: 1) the number of enrolments, evaluated against an estimated 30 enrolments (based on the high demand for training in the community with the current New Zealand training provider groups); and 2) course completion rate, estimated at greater than 85%. New Zealand data are lacking, but a US survey showed psychology-related programmes have low attrition rates, generally between 4% and 13% (see Michalski et al., 2016). Because such psychology-related programmes may not account for the unique challenges of training in EMDR, we estimated a slightly higher dropout rate of 15%. The paucity of published data on this aspect of EMDR training underlies the importance of identifying completion rates.

EMDR competency measurement. This will be assessed using CanMEDs summative assessment measures in all course assignments. These include reference to culturally responsive practice.

Incorporation of key stakeholder input. This will be assessed against the aim of recruiting a group of diverse and senior community stakeholders and engaging them in a co-design project that delivers an approach to assessing culturally responsive practice as an EMDR clinician.

Delivery of (1) learning outcomes and (2) Otago graduate profile attributes. Both of these aspects will be assessed using the CanMEDs measurement tools, which have been developed to incorporate indices of all components.

Student experience. Students’ experiences will be assessed using: 1) Higher Education Development Centre (HEDC) surveys that include quantitative and qualitative elements, incorporating standard university course assessment items and project specific items drawing on input from the researchers and the Stakeholder Advisory Group; and 2) qualitative data from post-course focus groups.

Teacher experience. We will assess teachers’ experiences using qualitative data from post-course focus groups.

Client experience. This aspect will also be assessed using qualitative data from post-course focus groups.

Data Collection and Measures

Course data. The number of students enrolled in the course and the number retained will be collected from university records. Students’ grades will be collected in de-identified form from university records, including scores on formative (practice) and summative (final) assessments to track progress. This will include overall grades and scores for competency domains based on the CanMEDS competency framework (e.g. on cultural competency).

Student experience surveys. The University of Otago has standardised forms for student surveys developed by its HEDC. These will include a set of core questions related to teaching and learning experience, with optional questions and the capacity to include paper-specific questions. The core questions will be included along with a set of questions selected for relevance to the course and evaluation aims. These surveys will be administered online to students following each teaching block and at the end of the course. The surveys use a mix of Likert scale responses and open text fields. Results from the Likert scale questions will be analysed across participants. Content analysis will be used to summarise themes from open-text fields.

Focus group/individual semi-structured interviews. We will hold focus group interviews (typically lasting 60–90 minutes) with groups of three to nine students (using purposive sampling if necessary to maximise diversity in responses) to explore their experiences in training and implementing EMDR in their clinical practice. We will also offer a second focus group for the three course teachers, and individual interviews (to maintain privacy) with clients of students completing the course. An interview guide will be produced, drawing on input from the Stakeholder Advisory Group and focusing on participants’ experiences, touching on expectations, opportunities and challenges.

Additional measures co-designed with the Stakeholder Advisory Group. Additional survey or focus group questions or measures may be incorporated into the above based on work outcomes with the Stakeholder Advisory Group, particularly regarding ensuring the course is fit for purpose in our local contexts.

Data Analysis

• For the CanMEDs quantitative measures, bivariate and multivariate analyses will be performed incorporating threshold scores (55% in assignments, 40% in viva), which can be used to assess performance against expectations.

• Assignments will also be assessed using content analysis for written work, incorporating what the students produce in their assignments and the markers’ comments to reveal themes around the student cohort’s relative strengths and challenges.

• Students’ feedback on teachers and course evaluation will be analysed quantitatively (for scores) and qualitatively for open content fields to identify themes in students’ experiences of the training.

• Focus group data will be coded and analysed using thematic analysis, incorporating Thomas’ general inductive method (Thomas, 2006), which is a development of Braun and Clarke’s thematic analysis methodology (Clarke et al., 2015).

Discussion

A broad range of evidence-based psychological treatments, including cognitive behavioural, psychodynamic and family therapies, have been taught routinely in New Zealand and overseas university settings for decades. EMDR has not, despite its relatively long-standing and increasingly emerging evidence base. Training health professionals in tertiary education allows for a natural integration of academic and practical learning elements and is the predominant model applied in medicine, nursing and allied health. Furthermore, it is increasingly recognised that evidence-based interventions must account for the context in which they are being delivered, with cultural context and the need for developing culturally responsive practices being critical (American Psychological Association Advisory Steering Committee for Development of Clinical Practice Guidelines, n.d.; Wilson et al., 2022). Scant research has been undertaken on EMDR training, and we have been unable to find any research exploring university training in EMDR or integrating cultural competency in EMDR training.

This study will investigate the feasibility of training EMDR competencies, including culturally responsive practice, in a university graduate course setting. It will incorporate co-designed elements developed with key stakeholders to maximise community impact. If proof of concept can be achieved, this study has potential to inform future delivery of EMDR training in tertiary education settings in Aotearoa New Zealand and internationally. Establishing robust university training in EMDR, which prioritises culturally sensitive practice, can be a model for developing safe and effective fit-for-purpose training that meets the contextual and cultural needs of the environment where it is being practised. This has obvious benefits for EMDR trainees and the vulnerable client groups experiencing the conditions that EMDR has been developed to treat. We also view our project design as having the capacity to improve client voices in delivering healthcare by adopting a co-design approach with an advisory group that includes service users. This will support the design and evaluation of training that is meaningful to clients, teachers and students.

Acknowledgements

We would like to acknowledge the individuals who agreed to be part of our Stakeholder Advisory Group, and the clinical psychologists who have undertaken teaching roles in support of the project.

Funding

This research is supported by a University of Otago Committed for the Advancement of Learning and Teaching (CALT) award, and a research donation from EMDR New Zealand.

Course Evaluation Status

A Stakeholder Advisory Group was appointed in April 2023, comprising a highly qualified team with backgrounds in health service leadership, EMDR practice, bicultural expertise, understanding of rainbow and other marginalised group needs and lived experience of EMDR treatment. At the time of drafting this article, all participants had been recruited other than those participating in the post-course focus groups; all course teaching had been completed; all teaching surveys and internal assignments (but not the final viva) had been completed; and the co-designed input to the survey material had been finalised.